Provider Demographics
NPI:1881031243
Name:LATYSHENKO, ILYA (MD)
Entity Type:Individual
Prefix:DR
First Name:ILYA
Middle Name:
Last Name:LATYSHENKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36000 DARNALL LOOP
Mailing Address - Street 2:ATTN:MCXI-DEM
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5095
Mailing Address - Country:US
Mailing Address - Phone:254-288-8303
Mailing Address - Fax:254-286-7055
Practice Address - Street 1:36000 DARNALL LOOP
Practice Address - Street 2:ATTN: MCXI-DEM
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5095
Practice Address - Country:US
Practice Address - Phone:254-288-8303
Practice Address - Fax:254-286-7055
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-00158207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine